Wednesday, October 30, 2013

The National Uniform Claim Committee has updated the CMS-1500 insurance claim form to accommodate the new ICD-10 codes and current standard for electronic health care transactions.

Known as "version 02/12" and approved by both the Centers for Medicare & Medicaid Services (CMS) and the Office of Management and Budget, the updated claim form includes revisions designed to improve the accuracy of data reported.

Two changes of note:

• Physicians can identify in Item 21 whether they are using ICD-9 or ICD-10, which will come in handy during the transition to the new codes in October 2014. As noted in a previous post, it depends on the actual date of service whether you use ICD-9 or ICD-10 on claims submitted after Oct. 1, 2014.

• The diagnosis field in Item 21 will allow up to 12 codes. The current form (version 08/05) is limited to four.

Other revisions will also help with accuracy. For instance, you will now be able to identify in Item 17 the role of the provider as “Ordering,” “Referring,” or “Supervising."

The start date for using the revised form has not yet been announced. However, Medicare anticipates implementing the revised claim form as follows:

• Jan. 6, 2014, through March 31, 2014 – Providers can use either the current form or the revised one.

• April 1, 2014 – Only the revised form can be used.

These dates are tentative and subject to change. CMS will provide more information as it is available. Also, CMS is updating the Medicare Claims Processing Internet Only Manual to instruct contractors and physicians regarding how to complete the revised form online and will post this information on the CMS website when it is available.

If you still submit paper claims, you would be wise not to purchase large quantities of the current form. If your practice submits electronic claims, you should speak to your software vendor to determine how and when your practice management system will be updated to accommodate the revised form.

"As a local company, we have the benefit of being able to talk with Arizonans directly about what they want from their healthcare plan," said Bill Harris, chief executive officer of Blue Cross Blue Shield of Arizona Advantage. "They've made it very clear they want the freedom to choose their doctors…close to home. Adding Scottsdale Healthcare to the network of our Blue Medicare Advantage plans, members will have expanded access to care."

The Medicare Annual Election Period for 2014 is October 15 through December 7, 2013. Coverage takes effect on January 1, 2014. The annual election period hasn't changed for Medicare, and it is different than the new Affordable Care Act open enrollment period which ends March 31.

The study by the Dartmouth Institute for Health Policy and Clinical Practice examined geographic variations in the drugs elderly Medicare patients received in 2010. Researchers mapped where patients got medications they clearly needed and where they got drugs deemed risky for the elderly. They also looked at differences in the use of so-called discretionary drugs, which they say are widely prescribed but of uncertain benefits.

The report's findings underscore those of a ProPublica investigation in May, which found that some doctors who treat Medicare patients often prescribe drugs that are dangerous or inappropriate for certain patients. ProPublica also found that the federal officials who run Medicare have done little to scrutinize prescribing patterns in their drug program, known as Part D, or question doctors whose practices differ from their peers.

Officials from the Centers for Medicare and Medicaid Services could not be reached to answer questions about the study. They have previously said that the primary responsibility for overseeing prescribing belongs to private insurers that administer the program. Still, they have acknowledged that Medicare should and will do more to track prescribing in Part D and follow up on unusual patterns.

The Dartmouth researchers did not look at the habits of individual doctors, asProPublica did, but instead looked at the percent of patients in each region who received certain types of medications. Regional boundaries were based on where patients would be referred for hospital care.

For example, 17 percent of elderly patients in Miami received a prescription for a dementia drug in 2010, while less than four percent of patients in Rochester, Minnesota, and Grand Junction, Colorado, got one. Nationally, the average was seven percent, according to the report, titled the Dartmouth Atlas of Medicare Prescription Drug Use.

There were similar differences by location for antidepressants. In Miami, almost one-third of elderly Medicare enrollees received at least one prescription for such drugs and about one-quarter of those in a swath of Louisiana did. In Honolulu, just seven percent got one.

The report does not address whether the patients had diagnoses that would warrant the use of these medications. It also does not include disabled patients under 65 who are also covered by Part D.

"We see that some clinicians are not achieving a level of effective medication use" compared to their peers, said Dr. Nancy Morden, a lead author of the report. "Conversely, some clinicians are putting their patients at much higher risk by using hazardous medications at a much higher rate than their peers."

The report does not tackle two of the most fraught issues in prescribing today: the use of narcotic painkillers and anti-psychotics, especially to treat dementia in the elderly.

Morden said she was surprised to find that, in some regions, large percentages of patients were getting discretionary drugs that were moderately beneficial, like those for acid reflux—and not getting the ones that could save their lives, like the beta blockers or cholesterol-lowering drugs.

"What are we doing?" she said. "It's surprising to me that we can use so much of our energy to pursue medications that give us far less in terms of health. I worry that it's coming at the cost of getting the effective medications."

People in some regions of the country are healthier than in others. But Morden said that does not explain the wide variations her group found in so many different categories of drugs. That may be a signal that patients are not being adequately informed about the risks, benefits, and costs of the drugs, she said. Doctors also may be unaware of how different their practices are from the peers in other parts of the country.

In the report, Morden and her co-authors encourage policymakers to seek ways of reducing geographic variation in the way medications are prescribed. They also urge patients to ask their doctors about whether a drug is truly needed for them.

The Dartmouth group has previously examined how costs and use of services in the Medicare program differ markedly across the country. They note that some of the highest-spending regions in terms of drug costs were also among the highest users of other types of medical services.

Health Dialog today announced that results from its recent study on Shared Decision Making have been included in the Healthcare Leadership Council's (HLC) 'The Future is Here: A Compendium of Healthcare Innovation' as one example of a health improvement concept that is making a positive impact on transforming today's healthcare system.

'Enhanced Support For Shared Decision Making Reduced Costs Of Care For Patients With Preference Sensitive Conditions', authored by David Veroff, senior vice president of innovation at Health Dialog, compared the effects on patients engaging in key health and treatment decisions receiving a usual level of support with the effects of receiving enhanced levels of support. The study, published in the 2013 February issue of Health Affairs, shows that compared with patients who received the usual level of support, patients who received enhanced support had:

"Health Dialog is demonstrating how improving the decision making process between physicians and patients can improve health and curb costs," said Mary R. Grealy, president of the Healthcare Leadership Council. "What Health Dialog is achieving exemplifies the message of this compendium, that today's healthcare leaders are successfully shaping a 21st century system that keeps people healthy, improves patient outcomes, maintains affordability and combats the escalation in chronic disease."

Thursday, October 24, 2013

ICD-9-CM is an official classification system that practitioners currently use to code diagnoses and procedures on health care claim forms in the United States. Organizations use ICD-9-CM codes from claim and encounter data to identify diagnoses and procedures for HEDIS reporting. The Centers for Medicare & Medicaid Services (CMS) has mandated that health care providers switch from ICD-9 to ICD-10 Diagnosis and Procedure codes, effective October 1, 2014.

To accommodate this change, NCQA created a plan to identify a valid and appropriate set of ICD-10 codes for each HEDIS measure in time for inclusion in the HEDIS 2015 publications. This identification has been in progress for three years and is now complete. NCQA seeks public comment on the final recommendations for converting ICD-9 to ICD-10 codes in HEDIS measures.

NOTE: This process and timeline is separate from the HEDIS Public Comment process and timeline.

Reviewing the Recommendations

Because of the large number of codes being reviewed, NCQA is providing reviewers with more time than usual to look at the recommendations and provide comments and suggestions. We suggest that reviewers look at the recommendations and submit comments in sections or phases. Reviewers are asked to submit their comments in writing using the ICD-10 Public Comment form by 9:00am (ET) on Monday, December 16, 2013.

Almost 2 years ago, ONC released meaningful use quick reference grids to capture—in one place—how meaningful use Stage 1 objectives and measures correlated with adopted 2011 Edition EHR certification criteria. We’re pleased to announce the 2014 versions of these grids, which are back by popular demand, and posted on HealthIT.gov (look under the “ONC Resources” heading).

2014 Meaningful Use Quick Reference Grids

This time around, because there are two meaningful use stages to which the single set of

Similar to the “original,” each meaningful use quick reference grid follows the same format:

The first two columns reference meaningful use objectives and measures and serve as the anchor around which the rest of the grid is organized.

The asterisks to the left of the objectives listed indicate whether the meaningful use objective is applicable to eligible professionals (EPs) only, eligible hospitals (EH) and critical access hospitals (CAHs) only, or all of the above.

The core set objectives and measures are listed first followed by the menu set objectives and measures.

The third and forth columns reference the certification criteria that correlate with each meaningful use objective and measure, and the standard(s) and implementation specifications referred to by each certification criterion, where applicable.

I hope you find these meaningful use objectives quick reference grids as useful (and hopefully timesaving) as we do.

Hospital officials said that laptops were password-protected and that there is no evidence the information has been accessed. However, they recommended that affected patients check their credit reports for fraud (AP/Atlanta Journal Constitution, 10/21).

On Tuesday, Alhambra police Sgt. Jerry Johnson said that detectives are looking for a suspect who was identified by reviewing the facility's video surveillance system (AP/Sacramento Bee, 10/22).

Details of Texas Breach

On Tuesday, officials at Seton Healthcare Family reported that a hospital laptop containing the personal health information of about 5,500 patients was stolen between Oct. 3 and Oct. 4, theAustin American-Statesman reports.

Seton officials said the laptop was discovered missing from the Seton McCarthy Clinic in East Austin on Oct. 4 and the situation was immediately reported to the police. They said they will contact individuals affected by the breach.

The laptop contained data including patients':

Names;

Addresses;

Phone Numbers;

Birth dates;

Insurance information;

Medical record numbers;

Diagnoses; and

Immunization details.

Seton officials said they do not believe the patient information "has been used inappropriately," but they said "a missed technology glitch during installation" caused the laptop to remain unencrypted (Grisales, Austin American-Statesman, 10/22).

Oct. 22 --The federal government gets $20 back for every dollar invested in False Claims Act health-care fraud cases, a higher rate than indicated by the Department of Justice's reporting on FCA settlements, according to a report from the Taxpayers Against Fraud (TAF) Education Fund released Oct. 22.

The report, “Fighting Medicare & Medicaid Fraud: The Return on Investment from False Claims Act Partnerships,” said that the DOJ's reporting doesn't include criminal fines associated with FCA cases or state recoveries associated with federal FCA cases, which together accounted for $9 billion in recoveries from fiscal year 2008 through FY 2012.

As a result, the DOJ's return on investment of 16-to-1 for FCA health-care fraud cases “is an understatement of the full 'rate of return' from the federal government's anti-fraud activities,” the report said.

Overall Recoveries

During the same time frame, the three agencies that investigate and prosecute health-care fraud FCA cases (the U.S. Attorney's Offices, the Department of Health and Human Services Office of Inspector General and the DOJ's Civil Division) received a total of $575 million from the Medicare trust fund for health-care fraud enforcement, the report said.

“While it is difficult to quantify federal and state costs associated with recovering these federal criminal and state civil dollars, we are confident that if all costs and benefits are accounted for, the benefit to cost ratio of False Claims Act law enforcement now exceeds 20:1,” the report said.

Whistle-Blower Cases

FCA cases involving health-care fraud whistle-blowers have increased dramatically since 1986, when penalties under the FCA were strengthened, the report said.

For example, from 1986 to 1992, there were 62 new health-care fraud whistle-blower referrals, investigations or actions. In comparison, there were 417 in 2011 and 412 in 2012.

In 2012, whistle-blowers received $284 million out of $2.5 billion in health-care fraud whistle-blower settlements.

The TAF report also said that criminal FCA cases are becoming increasingly important to the federal government.

“Not only do they bring in additional recoveries, but also they create the possibility of criminal conviction, which serves as a deterrent to committing fraud against the government,” the report said.

Criminal FCA cases also often are linked with civil FCA cases, the report said, as a civil investigation can lead to criminal charges.

Congressional Comment

Sen. Charles E. Grassley (R-Iowa), who wrote the 1986 amendments to the FCA, said the TAF report indicates the value of the FCA.

“The law has empowered whistleblowers to come forward, risk their careers and root out the shady characters looking to give the taxpayer a bad deal,” Grassley said in a statement released Oct. 22.

Although the focus in 1986 was on defense contractors, the FCA is “the most effective tool against health care fraud, as evidenced by the report released today,” he said.

Grassley said any attempts to weaken the FCA “should be met with skepticism by the courts and Congress.”

(Reuters) - Healthcare benefits provider Universal American Corp (UAM.N) sued private equity firm GTCR LLC on Tuesday to undo a $222.3 million acquisition it said was induced by fraud, a day after GTCR filed its own lawsuit to block Universal's claims.

The dispute goes to the heart of the business of the private equity industry, where firms buy companies and hope to sell them later at a profit. Finding interested buyers and avoiding the taint of fraud are crucial to a firm's ability to earn big profits for itself and its investors.

In a complaint filed on Tuesday in the U.S. District Court in Delaware, Universal claimed that GTCR misled it about the finances and businessprospects of APS Healthcare Inc ("APS"), a healthcare management services provider it bought in March 2012.Universal said "the ugly truth" emerged soon thereafter, with APS being declared in default by its biggest customer and losing some or all of its business with other large customers.

"Defendants engaged in a deliberate campaign to conceal the truth about APS," Universal said. "The avalanche of bad news ... the complete evaporation of APS's income within months, and the sheer number of misrepresentations and omissions in the merger agreement ... are all telltale signs of fraud."

The lawsuit was filed just 16 hours after Partners Healthcare Solutions Holdings LP, the GTCR company that sold APS, filed its own lawsuit in Delaware Chancery Court. It seeks a declaration that Universal's claims are baseless and the release of sums held in escrow after the merger closed.

While admitting that APS' earnings in 2012 "fell well short of what both parties had hoped," the GTCR company called the dispute "a straightforward case of buyer's remorse" that sought "to turn the seller into its scapegoat."

Universal and APS are based in White Plains, New York, while GTCR is based in Chicago.

A Universal spokeswoman declined to comment. GTCR did not immediately respond to a request for comment.

Wednesday, October 23, 2013

The federal physician self-referral statute, known as the Stark law,[1] prohibits a physician from referring to an entity for the furnishing of a designated health service if the physician (or immediate family member) has a financial relationship with the entity, unless the referral complies with a Stark exception. Physicians have long relied on the In-Office Ancillary Services Exception[2]when structuring ancillary service models as part of their medical practices.

However, the proposed “Promoting Integrity in Medicare Act of 2013,” being referred to as “PIMA,” (H.R. 2914) would eliminate this exception for advanced imaging (which includes MR and CT), anatomic pathology, radiation therapy, and physical therapy. PIMA would also increase the penalties under Stark for the newly prohibited self-referrals. If passed into law, H.R. 2914 will require physician practices that currently provide these ancillary services to restructure or unwind these service models completely.

H.R. 2914

H.R. 2914 was introduced in the U.S. House of Representatives on August 1, 2013 by Jackie Speier (D-CA), Jim McDermott (D-WA), and Diana Titus (D-NV). The bill cites recent reports by the U.S. Government Accountability Office (GAO) and the Medicare Payment Advisory Commission (MedPac) finding that physician self-referrals in the areas of advanced imaging, anatomical pathology, radiation therapy, and physical therapy drive up Medicare costs and negatively impact patient care.

According to Congresswoman Speier, “[n]ot only is Medicare wasting hundreds of millions each year on unnecessary or inappropriate care, in some cases it is downright harmful, such as when patients receive unnecessary CT scans, which involve the use of ionizing radiation that has been linked to an increased risk of developing cancer.”[3] Supporters of the bill include the American Clinical Laboratory Association, the American College of Radiology, and the American Physical Therapy Association, among other industry organizations.[4]

Opponents of H.R. 2914—which include the American Medical Association, the American College of Surgeons, and the American Urology Association, among other physician organizations[5]—argue that it would create barriers to care and drive up costs by forcing patients to obtain services at higher cost centers, such as hospitals and free-standing centers.[6]

According to the Coalition for Patient Centered Imaging, which represents various physician organizations, “H.R. 2914 would . . . force patients to receive services in a new and unfamiliar setting, increase costs, present significant barriers to appropriate screenings and treatments, and make health care less accessible.”[7] Others argue that the studies cited in the bill are flawed and that, if passed, independent physicians will lose the ability to compete in the market.[8]

Conclusion

The business implications of H.R. 2914 obviously are significant for both supporters and opponents of the bill. But if passed, its impact will be particularly felt by those physicians who have invested in these ancillary service lines in reliance on this Stark exception as it has existed up to now. The bill would go into effect one year after passage, requiring physicians to discontinue self-referrals for the targeted health services.

Donald Gibson, II, 57, of Sugar Land, is headed to prison following his conviction of conspiracy to commit health care fraud relating to medically unnecessary diagnostic testing and physical therapy, United States Attorney Kenneth Magidson announced today. Gibson entered a plea of guilty to conspiracy to commit health care fraud on April 1, 2013.

Today, U.S. District Judge Lynn H. Hughes, who accepted the guilty plea, took into consideration Gibson’s cooperation with federal authorities and handed him a sentence of 52 months in federal prison. Judge Hughes also ordered restitution in the amount of $6,943,478.87. The United States previously seized approximately $2.62 million in Gibson’s assets and froze another $505,455 Medicare was to pay to Gibson. As a result, these two amounts totaling $3,129,175 will be applied to Gibson’s restitution and subsequently returned to Medicare program.

As part of the scheme to defraud, Gibson ordered, prescribed, and authorized medically unnecessary diagnostic tests and other procedures, which included allergy tests, pulmonary function tests, vestibular tests, urodynamic tests, and physical therapy, among others. These services were then billed to Medicare and Medicaid for payment under Gibson’s billing number. Gibson worked in conjunction with the owners and operators of medical clinics and diagnostic testing centers in the Houston area. As part of the scheme, Medicare patients were paid to show up at the clinics for testing. Patient recruiters were also paid for recruiting and bringing patients to the clinics for the unneeded testing.

From January 2007 through January 2012, Gibson caused more than $19.4 million in medical claims to the Medicare and Texas Medicaid Programs. As a result, Medicare deposited approximately $8.5 million into a bank account owned and controlled by Gibson.

Gibson’s co-defendant, Sunday Joseph Edem, is scheduled to be sentenced by Judge Hughes on November 18, 2013.

This case is the result of a joint investigation involving multiple federal and state agencies, including agents and investigators of the U.S. Department of Health and Human Services-Office of Inspector General, Railroad Retirement Board, Secret Service, Drug Enforcement Administration, FBI, and the Texas Attorney General’s Medicaid Fraud Control Unit. Special Assistant U.S. Attorney Justin Blan and Assistant U.S. Attorney Andrew Leuchtmann are prosecuting this case with Assistant U.S. Attorney Kristine Rollinson overseeing the asset forfeiture.

CINCINNATI (AP) — Omnicare Inc., the nation's biggest dispenser of prescription drugs in nursing homes, said Wednesday it will pay $120 million to settle a whistle-blower lawsuit accusing the Cincinnati-based company of giving kickbacks to facilities in return for more patient referrals.

Under the settlement agreement, reached Tuesday, Omnicare does not admit liability. The agreement still needs to be approved by the Department of Justice and federal court, Omnicare said in a Securities and Exchange Commission filing Wednesday.

"Omnicare continues to deny that there was any wrongdoing," Patrick Lee, vice president of investor relations at Omnicare, said in a statement to The Associated Press.

"The company agreed to settle the matter in order to avoid continued litigation and to focus on its mission of helping to ensure the health of seniors and other patient populations in a cost-effective manner," Lee said. "Omnicare is committed to ensuring that it remains in strict compliance with all applicable laws, regulations and standards in each of the markets and jurisdictions in which it operates."

The settlement is the result of a lawsuit filed in federal court in Cleveland in 2010 by an Ohio pharmacist named Donald Gale who worked for Omnicare from 1993 until 2010, his attorneys say.

Gale, who stands to get between 25 and 30 percent of the settlement — or up to $36 million — accused Omnicare of violating the federal anti-kickback statute, which prohibits anyone from lying in applications for benefits under a federal health care program, such as Medicare.

The lawsuit accused Omnicare of giving steep discounts for prescription drugs to nursing homes for some Medicare patients in exchange for the referrals of other patients at higher prices paid for by the federal government.

"What Omnicare would do some of the time, when it wanted to keep the business of a nursing home, it would say, 'Well, we'll give you rock-bottom or below-cost prices on the drugs of your Medicare Part A patients' ... to get the rest of the patients to pay higher," said Virginia Davidson, one of Gale's attorneys.

She called the settlement a "pretty significant figure" and praised Gale, a 45-year-old resident of Wadsworth in northeastern Ohio, for filing the lawsuit.

"Not too many people sitting at work getting a paycheck are going to stand up and risk their livelihood by pointing out illegal conduct," she said.

The federal government would get between 65 and 70 percent of the settlement, or up to $84 million.

Omnicare settled another major lawsuit in 2009, when it agreed to pay $98 million stemming from allegations that it paid kickbacks to nursing homes to gain their business, and received kickbacks for buying and recommending drugs.

Those are very powerful words, particularly when used by a doctor. They can provide the slightest bit of comfort to a patient — or the family of a patient — and also allow the health care provider to express sincere compassion in a time when treatment did not meet expectations or worse, a loss occurred.

Doctors in Pennsylvania may finally be allowed to utter that phrase out loud. Not exactly groundbreaking legislation as 36 other states already have similar laws in place. However, for a state with an historically aggressive malpractice climate, the news is a giant leap forward.

Pennsylvania’s House of Representatives today passed the Benevolent Gesture Medical Professional Liability Act (SB 379) by a unanimous vote of 202-0. Earlier in the year, the state’s Senate passed the measure 50-0. This bill allows doctors to make benevolent gestures and not have those statements used against them as long as such statements are not an admission of negligence or fault.

“As physicians, it is part of our job – part of our moral and ethical responsibility – to respond to patients and families when there are less than favorable outcomes,” said C. Richard Schott, MD, president of the Pennsylvania Medical Society and a practicing cardiologist. “Medicine is not an exact science, and outcomes may be unpredictable. Benevolent gestures are always appropriate and physicians should not have to fear giving them.”

However, physicians should be aware that there are still restrictions as to what they should say and what can still be used against them in a malpractice suit. Mary Kate McGrath, an attorney with Marshall Dennehey Warner Coleman & Goggin in Pennsylvania, recently wrote:

Attempts to explain what happened during the course of treatment will remain admissible, even if the statements are made in the context of an apology. Words can be misinterpreted, therefore, it would be beneficial for health care providers to have communications be brief and witnessed by a third party. In order to enjoy the protections of the Apology Act at trial, it is essential for health care providers to know the difference between “I’m sorry” and “I was wrong.”

While some of the details will become clearer in time, docs can take a breath and know that, at minimum, they are allowed to say “I’m sorry” without worrying if it may later haunt them.

“This bill will help improve patient-doctor communications, while also helping trial lawyers who often have people call them thinking they have malpractice cases when the physicians didn’t say they were sorry,” said Dr. Schott.

The Justice Department on Tuesday announced a $12 million settlement with a mail-order diabetic supply company and its owners who have agreed to pay the fines to resolve civil and criminal health-care fraud charges stemming from an investigation into a kickback scheme involving Medicare and Tricare.

Owners of Kansas-based Global Medical and parent company Global Medical Direct, Robert Shea and Mark Franz, agreed to pay $7 million to settle charges that they submitted false claims to the government health care programs.

The companies also agreed to pay $5 million in proceeds to resolve a civil enforcement action.

The announcement came from New Orleans U.S. Attorney Kenneth Polite, whose office worked with federal prosecutors in Kansas, where the companies are based. The Office of Inspector General for the U.S. Department of Health and Human Services and the FBI worked on the investigation.

Shea and Franz are barred from participating in any federal healthcare program for 20 years as part of the deal, the Justice Department said.

Authorities said the investigation found that between April 2008 and January 2012, the owners engaged in a kickback scheme by entering contracts with marketing and insurance brokerage companies with a high percentage of diabetes patients that were referred for diabetic supplies. The federal anti-kickback statute makes it illegal to pay or get payment for patient referrals because of the potential for billing abuse of programs such as Medicare, the Justice Department said.